-
Question 1
Correct
-
You review a 65-year-old woman who is on the clinical decision unit (CDU) following a fall. Her son is present, and he is concerned about recent problems she has had with memory loss. He is very worried that she may be showing signs of developing dementia.
Which of the following is the most prevalent type of dementia?Your Answer: Alzheimerâs disease
Explanation:Alzheimer’s disease is the most prevalent type of dementia, making up around 55-60% of all cases. In the UK, the occurrence of Alzheimer’s disease is approximately 5 per 1000 person-years, and the likelihood of developing it increases with age.
-
This question is part of the following fields:
- Elderly Care / Frailty
-
-
Question 2
Correct
-
A 72-year-old woman is evaluated in the cardiac care unit 2 days after experiencing a heart attack. She complains of significant shortness of breath. During the physical examination, a pansystolic murmur is audible and is most prominent at the lower left sternal border.
What is the SINGLE most probable diagnosis?Your Answer: Ventricular septal defect
Explanation:Post myocardial infarction ventricular septal defect (VSD) is a rare but serious complication that occurs when the cardiac wall ruptures. It typically develops 2-3 days after a heart attack, and if left untreated, 85% of patients will die within two months. The murmur associated with VSD is a continuous sound throughout systole, and it is loudest at the lower left sternal edge. A palpable vibration, known as a thrill, is often felt along with the murmur.
Dressler’s syndrome, on the other hand, is a type of pericarditis that occurs 2-10 weeks after a heart attack or cardiac surgery. It is characterized by sharp chest pain that is relieved by sitting forwards. Other signs of Dressler’s syndrome include a rubbing sound heard when listening to the heart, pulsus paradoxus (an abnormal drop in blood pressure during inspiration), and signs of right ventricular failure.
Mitral regurgitation also causes a continuous murmur throughout systole, but it is best heard at the apex of the heart and may radiate to the axilla (armpit).
Tricuspid stenosis, on the other hand, causes an early diastolic murmur that is best heard at the lower left sternal edge during inspiration.
Lastly, mitral stenosis causes a rumbling mid-diastolic murmur that is best heard at the apex of the heart. To listen for this murmur, the patient should be in the left lateral position, and the stethoscope bell should be used during expiration.
-
This question is part of the following fields:
- Cardiology
-
-
Question 3
Incorrect
-
A 65-year-old patient arrives at the hospital after an acute digoxin overdose. She is experiencing nausea and complaining of irregular heartbeats.
Which of the following is NOT a reason to administer DigiFab to this patient?Your Answer: Potassium level of 5.5 mmol/l
Correct Answer: Prolonged seizures
Explanation:Digoxin-specific antibody (DigiFab) is an antidote used to counteract digoxin overdose. It is a purified and sterile preparation of digoxin-immune ovine Fab immunoglobulin fragments. These fragments are derived from healthy sheep that have been immunized with a digoxin derivative called digoxin-dicarboxymethoxylamine (DDMA). DDMA is a digoxin analogue that contains the essential cyclopentanoperhydrophenanthrene: lactone ring moiety coupled to keyhole limpet hemocyanin (KLH).
DigiFab has a higher affinity for digoxin compared to the affinity of digoxin for its sodium pump receptor, which is believed to be the receptor responsible for its therapeutic and toxic effects. When administered to a patient who has overdosed on digoxin, DigiFab binds to digoxin molecules, reducing the levels of free digoxin in the body. This shift in equilibrium away from binding to the receptors helps to reduce the cardiotoxic effects of digoxin. The Fab-digoxin complexes are then eliminated from the body through the kidney and reticuloendothelial system.
The indications for using DigiFab in cases of acute and chronic digoxin toxicity are summarized below:
Acute digoxin toxicity:
– Cardiac arrest
– Life-threatening arrhythmia
– Potassium level >5 mmol/l
– Ingestion of >10 mg of digoxin (in adults)
– Ingestion of >4 mg of digoxin (in children)
– Digoxin level >12 ng/mlChronic digoxin toxicity:
– Cardiac arrest
– Life-threatening arrhythmia
– Significant gastrointestinal symptoms
– Symptoms of digoxin toxicity in the presence of renal failure -
This question is part of the following fields:
- Pharmacology & Poisoning
-
-
Question 4
Incorrect
-
A 60-year-old woman has recently been diagnosed with Hodgkinâs lymphoma.
Which characteristic is considered to be a âBâ symptom of Hodgkinâs lymphoma?Your Answer: Fever > 37.5oC
Correct Answer: Night sweats
Explanation:The ‘B’ symptoms associated with Hodgkin’s lymphoma include fever, night sweats, and weight loss. Fever is defined as a body temperature exceeding 38 degrees Celsius. Night sweats refer to excessive sweating during sleep. Weight loss is considered significant if it amounts to more than 10% of a person’s body weight over a period of six months. It is important to note that pain after consuming alcohol is a distinctive sign of Hodgkin’s lymphoma, but it is not classified as a ‘B’ symptom. This symptom is relatively rare, occurring in only 2-3% of individuals diagnosed with Hodgkin’s lymphoma.
-
This question is part of the following fields:
- Haematology
-
-
Question 5
Correct
-
A 65-year-old patient presents with nausea and vomiting and decreased urine output. He has only produced a small amount of urine in the last day, and he has noticeable swelling in his ankles. His blood tests show a sudden increase in his creatinine levels in the last 48 hours, leading to a diagnosis of acute kidney injury (AKI).
What is an example of an intrinsic renal cause of AKI?Your Answer: Acute tubular necrosis
Explanation:Acute kidney injury (AKI), previously known as acute renal failure, is a sudden decline in kidney function. This results in the accumulation of urea and other waste products in the body and disrupts the balance of fluids and electrolytes. AKI can occur in individuals with previously normal kidney function or those with pre-existing kidney disease, known as acute-on-chronic kidney disease. It is a relatively common condition, with approximately 15% of adults admitted to hospitals in the UK developing AKI.
The causes of AKI can be categorized into pre-renal, intrinsic renal, and post-renal factors. The majority of AKI cases that develop outside of healthcare settings are due to pre-renal causes, accounting for 90% of cases. These causes typically involve low blood pressure associated with conditions like sepsis and fluid depletion. Medications, particularly ACE inhibitors and NSAIDs, are also frequently implicated.
Pre-renal:
– Volume depletion (e.g., severe bleeding, excessive vomiting or diarrhea, burns)
– Oedematous states (e.g., heart failure, liver cirrhosis, nephrotic syndrome)
– Low blood pressure (e.g., cardiogenic shock, sepsis, anaphylaxis)
– Cardiovascular conditions (e.g., severe heart failure, arrhythmias)
– Renal hypoperfusion: NSAIDs, COX-2 inhibitors, ACE inhibitors or ARBs, abdominal aortic aneurysm
– Renal artery stenosis
– Hepatorenal syndromeIntrinsic renal:
– Glomerular diseases (e.g., glomerulonephritis, thrombosis, hemolytic-uremic syndrome)
– Tubular injury: acute tubular necrosis (ATN) following prolonged lack of blood supply
– Acute interstitial nephritis due to drugs (e.g., NSAIDs), infection, or autoimmune diseases
– Vascular diseases (e.g., vasculitis, polyarteritis nodosa, thrombotic microangiopathy, cholesterol emboli, renal vein thrombosis, malignant hypertension)
– EclampsiaPost-renal:
– Kidney stones
– Blood clot
– Papillary necrosis
– Urethral stricture
– Prostatic hypertrophy or malignancy
– Bladder tumor
– Radiation fibrosis
– Pelvic malignancy
– Retroperitoneal -
This question is part of the following fields:
- Nephrology
-
-
Question 6
Incorrect
-
An older woman arrives at the Emergency Department in the afternoon, reporting chest discomfort. She has visited the hospital four times within the past two weeks with similar symptoms, and each time her examination and all tests came back normal. She lives alone but has family members living nearby. Her cat passed away recently. During today's examination, she appears to be in a slightly low mood. All systems examinations, ECG, and tests conducted today show no abnormalities.
What is the best course of action for managing this patient? Choose ONE option.Your Answer: Ask the care of the elderly team to review her
Correct Answer: Send a discharge summary to the GP outlining your findings and suggest that she may benefit from some social support
Explanation:When it comes to decision making and utilizing the wider medical team, it is crucial to always consider the possibility of new medical issues, even if the symptoms have occurred multiple times before. In the case of chest pain in elderly individuals, it is important to conduct further investigations, even if the presentation is similar to previous instances.
In addition, this patient appears to be displaying signs of depression. The loss of a pet can intensify feelings of loneliness. To address this, it would be wise to send a discharge summary to the patient’s general practitioner, outlining the findings and suggesting the potential benefits of providing social support for the patient.
By rephrasing and organizing the information with paragraph spacing, the explanation becomes clearer and easier to read.
-
This question is part of the following fields:
- Safeguarding & Psychosocial Emergencies
-
-
Question 7
Correct
-
A 35-year-old woman presents to the Emergency Department with a brief history of headaches, which are more severe in the morning, and blurred vision and ringing in the ears. Her headache is worse than usual today, and she has vomited multiple times. She has no significant medical history but does take the combined oral contraceptive pill. On examination, you find her to be overweight, and her neurological system examination reveals a sixth cranial nerve palsy, but no other focal neurology and fundoscopy reveals bilateral papilloedema.
What is the SINGLE most likely diagnosis?Your Answer: Idiopathic intracranial hypertension
Explanation:The most probable diagnosis in this case is idiopathic intracranial hypertension, also known as benign intracranial hypertension or pseudotumour cerebri. This condition typically affects overweight women in their 20s and 30s.
The clinical features of idiopathic intracranial hypertension include:
– Headache: The headache is usually worse in the morning and evenings, relieved by standing, and worsened when lying down. It can also be aggravated by coughing and sneezing. Some patients may experience pain around the shoulder girdle.
– Nausea and vomiting
– Visual field defects: These develop gradually over time.
– 6th nerve palsy and diplopia
– Bilateral papilloedemaTo investigate this condition, the patient should undergo a CT scan and/or MRI of the brain, as well as a lumbar puncture to measure the opening pressure and analyze the cerebrospinal fluid (CSF).
The primary treatment goal for idiopathic intracranial hypertension is to prevent visual loss. This can be achieved through one of the following strategies:
– Repeated lumbar puncture to control intracranial pressure (ICP)
– Medical treatment with acetazolamide
– Surgical decompression of the optic nerve sheath -
This question is part of the following fields:
- Neurology
-
-
Question 8
Correct
-
A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing. After evaluating him, you determine that he has community-acquired pneumonia. He has no significant medical history but has a known allergy to penicillin.
What is the most suitable antibiotic to prescribe in this situation?Your Answer: Clarithromycin
Explanation:This patient is displaying symptoms and signs that are consistent with community-acquired pneumonia (CAP). The most common cause of CAP in an adult patient who is otherwise in good health is Streptococcus pneumoniae.
When it comes to treating community-acquired pneumonia, the first-line antibiotic of choice is amoxicillin. According to the NICE guidelines, patients who are allergic to penicillin should be prescribed a macrolide (such as clarithromycin) or a tetracycline (such as doxycycline).
For more information, you can refer to the NICE guidelines on the diagnosis and management of pneumonia in adults.
-
This question is part of the following fields:
- Respiratory
-
-
Question 9
Correct
-
A 25-year-old bartender presents to the emergency department complaining of feeling unwell for the past week. He has been experiencing muscle aches, headaches, and fatigue. This morning, he woke up with a severely sore throat and noticed the presence of pus in the back of his throat. Upon examination, the patient has a temperature of 38.4ÂșC and both tonsils are covered in white exudate. Additionally, he has tender enlarged cervical lymph nodes and tenderness in the left and right upper quadrants of his abdomen, with a palpable liver edge.
What is the most likely cause of this patient's symptoms?Your Answer: Epstein-Barr virus
Explanation:This individual is experiencing early symptoms such as tiredness, swollen tonsils with discharge, enlarged lymph nodes, and an enlarged liver. Additionally, they fall within the typical age group for developing glandular fever (infectious mononucleosis). Epstein-Barr virus (EBV) is responsible for the majority of glandular fever cases.
Further Reading:
Glandular fever, also known as infectious mononucleosis or mono, is a clinical syndrome characterized by symptoms such as sore throat, fever, and swollen lymph nodes. It is primarily caused by the Epstein-Barr virus (EBV), with other viruses and infections accounting for the remaining cases. Glandular fever is transmitted through infected saliva and primarily affects adolescents and young adults. The incubation period is 4-8 weeks.
The majority of EBV infections are asymptomatic, with over 95% of adults worldwide having evidence of prior infection. Clinical features of glandular fever include fever, sore throat, exudative tonsillitis, lymphadenopathy, and prodromal symptoms such as fatigue and headache. Splenomegaly (enlarged spleen) and hepatomegaly (enlarged liver) may also be present, and a non-pruritic macular rash can sometimes occur.
Glandular fever can lead to complications such as splenic rupture, which increases the risk of rupture in the spleen. Approximately 50% of splenic ruptures associated with glandular fever are spontaneous, while the other 50% follow trauma. Diagnosis of glandular fever involves various investigations, including viral serology for EBV, monospot test, and liver function tests. Additional serology tests may be conducted if EBV testing is negative.
Management of glandular fever involves supportive care and symptomatic relief with simple analgesia. Antiviral medication has not been shown to be beneficial. It is important to identify patients at risk of serious complications, such as airway obstruction, splenic rupture, and dehydration, and provide appropriate management. Patients can be advised to return to normal activities as soon as possible, avoiding heavy lifting and contact sports for the first month to reduce the risk of splenic rupture.
Rare but serious complications associated with glandular fever include hepatitis, upper airway obstruction, cardiac complications, renal complications, neurological complications, haematological complications, chronic fatigue, and an increased risk of lymphoproliferative cancers and multiple sclerosis.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 10
Correct
-
You evaluate a 30-year-old woman with a confirmed diagnosis of HIV. She inquires about her diagnosis and has some questions for you.
Choose from the options provided below the ONE CD4 count that indicates advanced HIV disease (also referred to as AIDS).Your Answer: 200 cells/mm3
Explanation:A normal CD4 count ranges from 500-1000 cells/mm3. In individuals diagnosed with HIV, the CD4 count is typically monitored every 3-6 months. It is important to note that the CD4 count can fluctuate on a daily basis and can be influenced by the timing of the blood test as well as the presence of other infections or illnesses.
When the CD4 count falls below 350 cells/mm3, it is recommended to consider starting antiretroviral therapy. A CD4 count below 200 cells/mm3 is indicative of advanced HIV disease, also known as AIDS defining.
-
This question is part of the following fields:
- Infectious Diseases
-
00
Correct
00
Incorrect
00
:
00
:
00
Session Time
00
:
00
Average Question Time (
Mins)